Pharmacists across the United States want to bill for services that they are providing to patients. One of the largest areas of billable services is medication therapy management services. But there's one big problem.
Insurers aren't paying for them.
I mean, some of the Medicare Part D prescription drug programs are reimbursing pharmacists for comprehensive medication reviews (CMRs) and a few other services. But the medical insurers aren't paying.
In my state, I have yet to find an insurer who even gives pharmacists the ability to enroll as an individual medical provider. When I think about this, I see this as a failure of the organizations that represent pharmacists.
For years we have heard from the organizations about how pharmacists can improve patient’s quality of life thru pharmaceutical care, medication therapy management, whatever you want to call it. But we need to be recognized as providers in order to be able to bill for our services and show the results of our services.
Prescription drug plans aren’t going to reimburse us for these services because they aren’t the ones paying the medical bills for the patients. If Caremark had to pay for Mr. Smith’s ER visit from a preventable medication event, they might pony up some money for pharmacist services.
But the PBMs don’t have any skin in that game, so they could care less if Mr. Smith gets hospitalized.
Pharmacist services need to be sold to the medical insurers. And that’s the responsibility of the national organizations. The American Pharmacist Association should be leading the way on this.
When I think about the American Medical Association, I picture an organization that is looking out for the survival of their profession. One of the key components is getting appropriate reimbursement for services rendered. Heck, today on Twitter I found a link where the AMA was successful in having the cuts in reimbursement rates delayed. You know as well as I that the AMA will be successful in keeping their reimbursements. The physicians will stop being providers if the rates get cut.
I don’t know if I can say the same about the APhA. From what I see, the APhA would rather sit back and take a wait-and-see approach when it comes to issues like this. We don’t want to assert ourselves and piss off the physicians.
This has led us to the point where we are not recognized as medical professionals. We can’t enroll as individual health care providers. For 20 plus years of talk about pharmaceutical care and medication therapy management, we have exactly three CPT billing codes that we can use. The American Medical Association (the people who determine which CPT codes are to be used) has all the power when it comes to determining which services are going to be covered.
I would love to see the APhA step up and design a series of CPS codes (Current Pharmacist Service codes) that we can use to bill insurers. And then get the insurers to recognize us as individual providers.
Who says that pharmacists need to be at the mercy of physicians when it comes to billing for our professional services?
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Here's a thought. NCPDP 5.1 and later include a feature known as DUR/PPS.
Specifically, fields 439-E4, 440-E5 and 441-E6. These codes respectively represent: Reason For Service, Professional Service Code, and Result of Service Code.
The general use of this system is to allow Point of Sale override of DUR software warnings ("soft" warnings) from the PBM's software. The system allows for the selection of an issue being addressed, a professional service by an RPh to address it (from a blinding array of choices, from MD consult, compendia consult, clinical judgement, patient counseling), and an outcome (usually, filled Rx, but can be a large number of things.)
Now. The key point of this system, is that these submitted codes can be tied to reimbursement. The software is smart enough to alter payment based on what codes are submitted. I have heard of one or two plans using this to pay for vaccine administration.
There's bit of interest to say the least. There's also a bit of caution - in the past, when submitted codes have been implemented, such as using ICD9 to bypass PA, there have been problems. Notably when some pharmacies find an ICD9 for a particular drug that works and submit it with ALL claims on that drug, regardless of a patient being Dx'd.
As PAS has mentioned there must be a way to code it in the filling software so pharmacists could bill for patient care services. It is a simple matter of software upgrading. We have to simply force the issue on the healthcare system and not only demand to be paid but explain why we are worth those payments.
I think the first step for all pharmacists is to get an NPI number if they don't already have one. I am getting one. My employer actually wants me to get one now.
The AMA is effective because it is a strong unified voice for the medical professionals around the country. Don't get me started on why I think that there isn't a pharmacy equivalent of the AMA but there should be. No one else is going to fight for our best interests but ourselves. The quicker we collectively realize that as a profession the better!
Redhead..I got my NPI about 3 weeks ago. Not that I remember it..but i have it...
What I envision is more like a physician's super-bill, except that it is done thru a PDA. Check a couple boxes and the software bills the insurance appropriately. More to follow.
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